Purpose: We present our experience with retroperitoneoscopic lymphatic disconnection for the treatment of patients with intractable chyluria. Materials and Methods: From November 1996 to March 2003, 12 patients (three females and nine males), with intractable chyluria were treated at our department with the retroperitoneoscopic technique. Diagnosis was based on urine examination for the presence of chyle and fat globules, cystoscopy, excretory urogram and retrograde ureteropyelography. The technique of retroperitoneoscopic management of chyluria consisted of nephrolympholysis, ureterolympholysis, hilar vessel stripping, fasciectomy and nephropexy. The first three procedures were done in all cases, whereas fasciectomy was only done in four cases and nephropexy in three as required. Results: Chyluria disappeared in all ipsilateral renal units of the patients who underwent retroperitoneoscopic management but it recurred in two patients at 1 and 9 months of follow up from the contralateral side. Both the cases have since been successfully treated with contralateral retroperitoneoscopic management. Complications included lymphatic leak through the drain, which persisted for 5 days in one case and an inadvertent clipping of a branch of the posterior segmental artery of the kidney in one. The latter patient did not have pain or hypertension and the renal scan did not reveal any focal deficit at follow up. All patients were followed periodically from 6 to54 months (mean of 31 months). Conclusion: Retroperitoneoscopic chylolymphatic disconnection is a safe and effective management of intractable chyluria. The reroperitoneoscopic approach provides direct access to the kidney without transgressing the peritoneum.

Surgical treatment of chyluria is restricted to patients with severe symptoms, i.e. weight loss, recurrent chyluria, clot retention, severe anaemia, hypoproteinemia, anasarca and chyluria not responding to conservative treatment and sclerotherapy. The open operation has been described by Dr. Phani Bhushan Prasad and commonly known as Patna operation, in which stripping of the lymphatics has been done by open operation.[1] With the advent of laparoscopy, such cases can be managed by minimally invasive approach. Cases have been reported via both transperitoneal and extraperitoneal access.[2],[3],[4],[5] We present our experience with retroperitoneoscopic lymphatic disconnection in 17 renal units for the management of intractable chyluria.

Materials and methods

From November 1996 to March 2003, 12 patients (three females and nine males), 25-55 years old with intractable chyluria (duration 2-11 years) were treated at our department with the retroperitoneoscopic technique. The presenting complaints included passage of milky white urine, often associated with passage of clots, intermittent retention of urine, flank pain and aggravation of symptoms after fatty meals and exercise. Patients experienced significant weight loss (5-15 kg) and all had been medically treated for filariasis previously. Blood profile revealed hemoglobin 8.5-11.5 gm/dl and albumin 2.4-4.0 gm/dl. Excretory urogram revealed paracaliceal lymphatics on the right side in only one case and no abnormality in the others. Cystoscopy showed right chylous efflux in seven patients and bilateral in the remaining five. Retrograde ureteropyelogram in the same setting demonstrated bilateral pyelolymphatic connections in five patients and unilateral involvement in four. In all patients, conservative treatment like bed rest, a fat restricted high protein diet and coconut oil as the cooking medium all had failed. They also had undergone multiple attempts of sclerotherapy, which worked temporarily. All patients were given general anaesthesia and were catheterized before the procedure. The technique of retroperiotoneoscopic access was similar to that described previously.[2] The patient is placed in kidney position and the primary port is placed 1.5-2 cm below and posterior to the tip of the 12th rib. Carbon dioxide pneumoretroperitoneum is created to a pressure of 15 mm Hg and the laparoscope is introduced. After confirming the adequacy of the retroperitoneal space, a second 10 mm cannula is introduced under vision in the line of the first port, about 2 cm above the iliac crest. A third 10 mm cannula is inserted in the midaxillary line 2 cm below the costal margin. Initially we used five procedures to perform retroperitoneoscopic management of chyluria, which were: (1) Nephrolympholysis: the kidney is dissected of its surrounding perirenal fascia, (2) Hilar stripping (skeletonization of the renal vessels and dilated perihilar lymphatics are individually clipped and divided), (3) Ureterolympholysis (downward mobilization of the ureter up to the common iliac vessels), (4) Fasciectomy (removal of perirenal fat) and (5) Nephropexy (the renal capsule is fixed to the psoas fascia at the upper, middle and inferior pole regions to prevent hypermobility). Nephrolympholysis, ureterolympholysis and stripping of hilar vessels were done in all cases. Fasciectomy and nephropaxy were done in a few patients and are not recommended routinely.[2] Gerota's fascia is divided and the kidney is dissected gradually out the perirenal fascia starting posteriorly followed by dissection of the upper pole, lower pole and finally the anterior surface. Once the kidney is completely mobilized, dissection of the renal vessels is started posteriorly. Vascular dissection is done with the utmost care. The dilated perirenal and perihilar lymphatics are individually clipped and divided. The renal vessels are laid bare of perivascular tissue. The dilated lymphatics are diligently searched for and clipped under laparoscopic magnification. Once posterior dissection is complete, the anterior surface of the vessels is cleared of loose areolar tissue and lymphatics. As much of the perirenal fat as possible is removed but this was done in only four cases. If the kidney is free within the retroperitoneal space and is hypermobile, it is fixed to the posterior abdominal wall using two or three sutures on the upper, middle and lower poles of the kidney or at either pole. This step is undertaken to avoid tension on the renal vessels and was done in only 3-17 renoureteral units. The retroperitoneum is irrigated with saline and inspected for hemostasis, and a drain is placed. After desufflation, the port sites are closed with muscle and skin sutures.

Results

Mean operating time was 111 min (range 90-145 min) average blood loss was 95 ml with a mean hospital stay of 2.6 days. We administered 75 mg diclofenac sodium intramuscularly for analgesia at 8 or 12 h in the first 24 h. Patients requiring analgesia were subsequently switched to 50 mg diclofenac sodium orally every 8 h for another 12-24 h. Chyluria stopped immediately in all patients after reroperitoneoscopic management. Oral intake was allowed on postoperative day 1. The drain was removed on postoperative day 1 or 2 except in one patient in whom it was kept for 5 days because of persistent leakage of lymph. The patients were discharged home the day following removal of the drain. In one case a posterior segmental artery branch was inadvertently clipped and divided without any consequence at follow up. In two cases chyluria recurred from the contralateral side at 1 and 9 months postoperatively, and both were successfully treated with retroperitoneoscopic management. Another three patients with bilateral efflux, who were initially treated with retroperitoneoscopic management on one side and sclerotherapy on the contralateral side in the same setting with dietary advice had no recurrence at last follow up. All patients became asymptomatic and gained weight, and serum albumin returned to a normal range (4.0-5.5 gm%). Follow up of these patients is now available for 6-54 months (average of 31). Follow up included subjective and objective evaluation of patients with the assessment of urine for chyle in the postoperative period, every 6 months for 2 years and then annually. The period of follow up ranged from 6 to 54 months (average 31). One patient whose branch of posterior segmental artery was inadvertently clipped and divided did not have any pain or hypertension at follow up, and the renal scan did not reveal any focal deficit.

Discussion

Chyluria is the passage of chyle into the urine giving it a typical milky appearance, it's due to a communication between lymphatic and urinary system. Filariasis is the most frequent cause of chyluria. Treatment of chyluria consists of conservative measures like bed rest, fat restricted high protein diet and use of fat containing medium chain triglycerides.[6] Since filariasis is the most common cause in this region multiple courses of antifilarial drugs may be required. Once the conservative treatment fails sclerothrapy should be next treatment. Patients with intractable chyluria, weight loss, clot colic or urinary retention in spite of sclerothrapy should under go surgical intervention. For recurrent chyluria the various treatment described are re-sclerotherapy, open or laparocopic chylolymphatic disconnection, microsurgical lympho-venous anastomosis and autotransplantation.[1],[2],[6],[7],[8] Among these chylolymphatic disconnection is the preferred treatment these days.[2],[3],[4],[5],[6] The procedure can be done by both open surgical technique and laparoscopy.[1],[2],[6] The success rate of open surgical technique has been reported up to 98% at follow up of 1 year.[6] Laparoscopy in spite of being minimally ivasive has all the advantages of open surgery [Table - 1]. Several authors have reported equally comparable results after laparoscopic chylolymphatic disconnection. [2],[3],[4],[5] Ours is the largest series of retroperitoneoscopic chylolymphatic disconnection from India. The advantages of retroperitoneoscopic chylolymphatic disconnection are; easy and straight access to the kidney, besides the other advantages of laparoscopy like magnified view for better identification of lymphatics, minimal morbidity, shorter hospital stay and lesser time off.

Conclusion

Patients with recurrent chyluria who fail to respond to re-sclerotherapy and other conservative measures should under go chylolymphatic disconnection. The reroperitoneoscopic approach provides direct access to the kidney for chylolymphatic disconnection without transgressing the peritoneum. The procedure is a safe and effective for the management of intractable chyluria. It has all the advantages of minimal invasive procedure.